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preface
Pocket Primary Care is dedicated to you, our readers, and to the patients we
care for. Thank you for choosing this text to guide your clinical decision
making. You may be using this book in an examination room, with a
patient, hoping to find medical advice to solve a clinical problem. Or you
may be reading this in a call room, late at night, to learn more about the
field of outpatient medicine. This book may find a home in the pocket of
your white lab coat, next to your stethoscope or N95 mask. The fact that
you read Pocket Primary Care, or any other text or online resource,
highlights your commitment to providing the best care to your patients.
Thank you for your desire to learn more to help patients. Wherever you are
practicing, and however you plan to use this book, thank you for entrusting
us with the opportunity to provide you with the most current and useful
information in outpatient internal medicine.
As a third-year medical student, I remember reading Dr. Sabatine’s
Pocket Medicine, and wondering how I could possibly absorb all of the
information he so masterfully presents. My goal was to read the entire book
during my internal medicine clerkship, and so during quiet moments on the
wards and on overnight shifts, I read Pocket Medicine in the call rooms of
the Johns Hopkins Hospital.
I was worried I would never be ready for the
intern year, nor would I ever master the breadth and depth of internal
medicine.
As a second-year resident at the Massachusetts General Hospital, it
became apparent that there was an enormous unmet need for an outpatient
version of Pocket Medicine that could be quickly referenced to answer
questions like what the best antibiotic for a UTI or how lower back pain
should be managed. The breadth of outpatient internal medicine is
astounding, and the responsibility and ownership primary care physicians
have to patients is enormous. And so, with a spirit of humility, Meghan
Kiefer, our co-authors, and I set out to create Pocket Primary Care. Thank
you to the dozens of contributors to this and previous editions of Pocket
Primary Care.
Ten years later, Pocket Primary Care hopes to bring the latest evidencebased medicine to the bedside for providers and for our patients. The
COVID-19 pandemic has transformed our world and internal medicine in
many ways. Pocket Primary Care hopes to adapt to these changes, by
presenting updated content on telehealth visits, care of patients with
COVID-19, and the latest in staples like cardiology and infectious disease.
It is always our goal to provide you with the most relevant information so
that you can provide the best care to your patients.
To become a health care provider, one must demonstrate through actions
like volunteer work, and in countless personal statements and applications,
a desire to help others. While it may seem a cliché, this sense of altruism is
what holds the health care system together. Hospitals and clinics could not
function without the relentless dedication to patient care that you provide.
This is even more true during the COVID-19 pandemic when health care
providers sacrificed family time, their health, and sometimes even their
lives, in the service of patient care. While others worked from home, health
care providers put on masks, worked overtime, and spent nights and
weekends in the hospital to care for patients. Thank you for your
dedication.
Considerations in Study Review
• Internal validity: Can I believe these results? Does study accurately
answer its question?
• Bias/study design: Depending on nature of bias, can minimize or
exaggerate true association; intrinsic to study itself
Selection bias: Primarily an effect of how study was designed. Other
than the known way they differ (exposed/unexposed in cohort,
disease/healthy in case control), how comparable are the two groups?
Are they from the same time period, geographic location, SES,
occupational group? Was one group more likely to be “lost to followup?” & thus not to have their events counted?
Information bias: Primarily an effect of how data were collected. Pts w/
known diseases may be prone to diff recall of exposure(s), providers
may have different testing patterns for pts w/ RFs or elicit different
hx based on presence/absence of disease; nature of measurement may
differ across groups (minimized by blinding)
• Confounding: Minimized by randomization in RCT, but major
limitation of observational studies; when the assoc between 2 factors is
at least partially explained by another, unmeasured factor; can lead to
misattribution (e.g., HRT assoc w/ ↓ CAD risk in cohort study, but only
because healthier women more likely to take HRT & less likely to have
CAD; all other things being equal, HRT can actually ↑ CAD risk)
• External validity: Do these results apply outside the context of this
study? Was study pop drawn from community it is meant to represent
(e.g., people willing to enroll in wt-loss study may be more willing to
start exercise program than random sampling from general pop)? Who
was excluded from the study? How pragmatic was the intervention (e.g.,
were participants called weekly to ensure adherence?)
• Applicability: How closely do study subjects resemble my pt?
• Generalizability: Can the results of this study be replicated elsewhere?
HEALTH LITERACY
Background (AFP 2015;92:118; Institute of Med 2004; NEJM 2010;363:2283)
• Definition: Set of skills/abilities needed to gain access to, understand, &
use health-related info; interaction between individual skills & health
system demands
• Numeracy: Related concept; the math skills needed for timing,
scheduling, dosing medications, & understanding math concepts
(arithmetic, percentages, probability) to understand & apply provider
recommendations
• Epidemiology: 33% of U.S. adults read at <5th grade level; 55% have
difficulty w/ basic calculations; 36% have basic or below-basic health
literacy (e.g., unable to calculate healthy BMI on chart for a given ht,
unable to correctly interpret Rx
label re: Timing of medication in
relation to food
